IMPROVING PRIMARY HEALTHCARE IN THE STATE OF JAMMU & KASHMIR

16-Oct-12

J & K: Paper on possibilities of PPP at J & K

Public-Private Partnership (PPP) has emerged as one of the important strategies for health sector reforms in J & K. Initiatives have been taken by NRHM, Health & FW Dept. to undertake different PPPs in meeting the growing needs for health services, including RCH-II and other National Health Programmes like Malaria, TB etc. There is a tremendous scope today in the state for exploring innovations in healthcare by DJVOW, towards reducing the MMR & NMR.

Improving Primary Healthcare in the state of Jammu & Kashmir

Improving Primary Healthcare in the state of Jammu & Kashmir

SAVING LIVES WITH LOW COST INNOVATIONS
BACKGROUND Recognizing the importance of Health in the process of economic and social development and improving the quality of life of our citizens, the Government of India has resolved to launch the National Rural Health Mission to carry out necessary architectural correction in the basic health care delivery system. The Mission adopts a synergistic approach by relating health to determinants of good health viz. segments of nutrition, sanitation, hygiene and safe drinking water. It also aims at mainstreaming the Indian systems of medicine to facilitate health care. The Plan of Action includes increasing public expenditure on health, reducing regional imbalance in health infrastructure, pooling resources, integration of organizational structures, optimization of health manpower, decentralization and district management of health programmes, community participation and ownership of assets, induction of management and financial personnel into district health system, and operationalising community health centers into functional hospitals meeting Indian Public Health Standards in each Block of the Country. The Goal of the Mission is to improve the availability of and access to quality health care by people, especially for those residing in rural areas, the poor, women and children. Infant Mortality Rate of the State was 51 in 2007 and has declined to 43 in 2010,Neonatal Mortality rate was 39 in the year 2007 and has declined to 35 in the year 2010 .Under 5 Mortality rate declined from 55 in 2008 to 48 in 2010.These indicators shows the impact of services provided under NRHM. Although the current IMR at 43/1000 live births is lower than National Average of 47/1000 live births, the Neonatal Mortality rate is still higher. Jammu & Kashmir is Indias northern-most state, lying between six mountain ranges and covering an area of 2, 22,236 sq. kilometers. It is located between 3217' and 3658' North latitude, and between 3726' and 8030' East longitude. The state commonly known as Kashmir is bounded on the north by Afghanistan and China, on the east by China, on the south by the state of Himachal Pradesh and the state of Punjab in India, and on the west by the North-West Frontier Province and the Punjab Province of Pakistan. Jammu and Kashmir actually comprises of three regions: the foothill plains of Jammu; the lakes and blue valleys of Kashmir rising to alpine passes, the high altitude plains and starkly beautiful mountains of Ladakh which lies beyond narrow passes. The state has been divided into 2 divisions (Jammu and Kashmir) and 22 districts for administrative purposes. Kashmir valley is covered by forested mountains, lakes, waterways and terraced fields. The Jammu region comprises of plains, mountains and foothills boasting of famous hill top shrine of Mata Vaishno Devi. Ladakh accounts for nearly two third of the states area and is a high altitude deserted region. The region is encompassed by oasis villages and ancient Buddhist monasteries. There are many low lying valleys viz. Tawi Valley, Chenab Valley, Poonch Valley, Sind Valley and Liddar Valley, but the main Valley is the valley of Kashmir which is 100 kms wide and 15520.3 sq. kms in area. Through this valley flows the Jhelum River with its tributaries. The average height of this valley is about 1700 metres above sea level. Some major rivers flowing through the region include Indus, Jhelum and Chenab.

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Improving Primary Healthcare in the state of Jammu & Kashmir

State of Jammu and Kashmir comprises of three regions viz Kashmir, Jammu and Ladakh. The State is further divided into 22 districts, two in Ladakh, 10 each in Jammu and Kashmir. The number of Tehsils and CD Blocks are 82 & 142 respectively. There are as many as 6652 villages and 68 urban areas besides 7 urban agglomerations. The total geographical area of the state is 2,222,36 sq. Kms. Which includes 78,114 sq. Kms under POK, 37,555 sq. kms. under illegal occupation of China in Ladakh and 5180 sq. kms illegally handed over by Pakistan to China. The State has population density of 45 per sq. km. (as against the national average of 312). The decadal growth rate of the state is 31.42% (against 21.54% for the country) and the population of the state continues to grow at a much faster rate than the national rate. HEALTH INDICATORS OF JAMMU & KASHMIR The Total Fertility Rate of the State is 2.3. The Infant Mortality Rate is 51 and Maternal Mortality Ratio is NA (SRS 2004 - 2006). The Sex Ratio in the State is 892 (as compared to 933 for the country). Comparative figures of major health and demographic indicators are as follows : Table I: Demographic, Socio-economic and Health profile of Jammu & Kashmir State as compared to India figures S. No. 1 2 3 4 5 6 7 8 9 10 11 12 Item Total population (Census 2001) (in million) Decadal Growth (Census 2001) (%) Crude Birth Rate (SRS 2007) Crude Death Rate (SRS 2007) Total Fertility Rate (SRS 2007) Infant Mortality Rate (SRS 2007) Maternal Mortality Ratio (SRS 2004 - 2006) Sex Ratio (Census 2001) Population below Poverty line (%) Schedule Caste population (in million) Schedule Tribe population (in million) Female Literacy Rate (Census 2001) (%) J&K 10.14 31.42 19.0 5.8 2.3 51 NA 892 3.48 0.77 1.11 43.0 India 1028.61 21.54 23.1 7.4 2.7 55 254 933 26.10 166.64 84.33 53.7

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Improving Primary Healthcare in the state of Jammu & Kashmir

Table II: Health Infrastructure of Jammu & Kashmir Particulars Sub-centre Primary Health Centre Community Health Centre Multipurpose worker (Female)/ANM at Sub Centres & PHCs Health Worker (Male) MPW(M) at Sub Centres Health Assistant (Female)/LHV at PHCs Health Assistant (Male) at PHCs Doctor at PHCs Obstetricians & Gynaecologists at CHCs Physicians at CHCs Paediatricians at CHCs Total specialists at CHCs Radiographers Pharmacist Laboratory Technicians Nurse/Midwife Required 1666 271 67 2282 1907 375 375 375 85 85 85 340 85 460 460 970 In position 1907 375 85 1794 27 89 451 28 44 17 135 59 557 396 403 Short fall 488 348 286 57 41 68 205 26 64 567

(Source: RHS Bulletin, March 2008, M/O Health & F.W., GOI) The other Health Institution in the State are detailed as under: Health Institution Medical College District Hospitals Referral Hospitals City Family Welfare Centre Number 4 22

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Improving Primary Healthcare in the state of Jammu & Kashmir

Rural Dispensaries Ayurvedic Hospitals Ayurvedic Dispensaries Unani Hospitals Unani Dispensaries Homeopathic Hospitals Homeopathic Dispensary 2 273 2 235 -

AVERAGE RURAL AREA AND AVERAGE RADIAL DISTANCE COVERED BY A PRIMARY HEALTH INSTITUTIONS. Average Radial Distance ( Average Rural Area (Sq. Km) Health Institutions Kms.) covered by a Health covered by a Health Intuitions Institutions J&K Sub Centre Primary Health Centre 117.21 All India 21.47 J&K 6.111 All India 2.61

591.67

139.40

13.72

6.66

Community Health Centre

2766.07

770.90

29.67

15.66

J&K SPECIFIC CONSTRAINTS Low density of population Difficult Terrain- problem of accessibility Poor Road Connectivity Limited presence of Private Sector/NGOs Private sector largely owned/operated by in-service doctors/specialists There is thus a very large scope of affecting improvements in the MMR, NMR and other indicators of the state through effective partnerships with the private sector through PPP. These partnerships can be based on the need base at grassroot level and the limitations of the current state machinery.

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Improving Primary Healthcare in the state of Jammu & Kashmir

ONE|MOBILE DENTAL CLINICS FOR J & K

CREATION OF ACCESS TO NEW SERVICES

A. STATE SPECIFIC BACKGROUND

Even though some level of primary dental care is available in some public health facilities in the state, most dental procedures are not done at this level and dentures are not made anywhere. In the private Dental facilities, dentures are made through a referral linkage. But in the Public System the patient is expected to visit the dental college.

B. NEED IN CONTEXT
J & K is a state with the health care delivery system skewed in favour of urban areas. Most of the dental facilities available in the state are privately owned with its implications of high cost and is urbanized, which leaves out a large part of the population esp. the elderly, women and children without access to quality dental care.

C. EXPECTED BENEFITS
A series of Mobile Dental Vans at District level will allow access to dental procedures which are unavailable to the rural population and often associated with high out of pocket expenses. The Dental Vans could also add value to the School Health Program by visiting the schools and participating in preventive health checkups and orientation to the children.

D. STRATEGY
A robust PPP with the private sector players will ensure extension of technical support to the state in terms of Mobile vans & equipment and supply of trained manpower including dentists and dental technicians.

E. SOURCE OF FUNDS
NRHM Flexi Pool Part B

F. APPROVING AUTHORITY
Mission Director NRHM

G. ESTIMATED PROJECT SIZE

2.5 Cr for Pilot Phase covering 5 remote districts

H. CURRENT STATUS OF PIP BASED APPROVAL

Current PIP supports innovation
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Improving Primary Healthcare in the state of Jammu & Kashmir

TWO|CALL CENTRE BASED HELPLINE -104

CREATION OF NEW SERVICES AND INCREASING ACCESS The Government of India accorded approval to set health advice call centre in PIP of NRHM during 2011-12. The objective of the health advice call centre is 24x7 medical advices to health care seekers for quick decision to provide smooth, effective and qualitative health care.

A. STATE SPECIFIC BACKGROUND

A dedicated call centre operational 24 x 7 can be a backbone for the various services extended by the Govt. hospitals across the state and could play a critical part in coordinating and facilitating access to the population seeking specific health services.

B. NEED IN CONTEXT
The health advice will be given to the caller who will dial simply a 3 digit toll free number 104 from landline or any mobile phone. To begin with the call centre may be rendering advice to the common man, ANMs, ASHA workers, School Health Personnel and Medical Officers of remote PHCs

C. EXPECTED BENEFITS
It will guide the community and health service provider personnels for timely referral, proper intervention & manag. of the patients and effective implementation of National Health Programs. It will work as an effective tool for Disease Surveillance and also in Disaster Management. Specialists advice by Pediatrician, Gynecologist and Public Health Specialists will be available

D. METHODOLOGY
A PPP based initiative will be affected where the Technical Service Provider will assure the State Govt. all Infrastructural and Process oriented services against a fixed fee. It will be the responsibility of the TSP to procure all equipments and manpower, train them and deploy effectively.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 3 to 5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

THREE|INTER FACILITY AMBULANCE BASED REFERRAL

CREATION OF NEW SERVICES AND INCREASING ACCESS NRHM envisages Post-Hospital Care Emergency Transportation (Ambulance) services within the States

A. STATE SPECIFIC BACKGROUND

The 11th five year plan approach emphasizes development of a Good health care infrastructure and providing quality health care Services. Simultaneously, today the state government is focusing on Technology-based solutions, like Tele-medicine, Emergency Ambulance Care, and free IPD and OPD health care for BPL families through a number of innovative schemes.

B. NEED IN CONTEXT
Post Emergency supervised secondary evacuation referral services are required for taking care of the patients requiring referral to higher center.

C. EXPECTED BENEFITS
Improve the access to higher medical & health care, police and fire services, particularly attending to the emergency situations relating to pregnant women, neonates, parents of neonates, infant and children in situations of serious ill-health and all other emergencies in the general population; and thereby assist the State to achieve the critical Millennium Development goals.

D. METHODOLOGY
A PPP based initiative will be affected where the Technical Service Provider will assure the State Govt. all Infrastructural and Process oriented services against a fixed fee. It will be the responsibility of the TSP to procure all equipments and manpower, train them and deploy effectively. This service will link up with the existing 108 pre hospital emergency ambulance services by EMRI.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 3 to 5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

FOUR|STRENGTHENING NEW BORN CARE CORNERS FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS India accounts for 30 per cent of the neonatal deaths globally. In India, the NMR is 37/1,000 live births. Most of these deaths occur within the first days of life: 46.2 per cent occurring in the first two days of life and 73.3 per cent taking place within the first week of life. Thus, serious, concerted efforts have to be made to address the needs of a newborn in its first days in Order to reduce NMR

A. STATE SPECIFIC BACKGROUND

The state has implemented NBCCs but utilization is poor

B. NEED IN CONTEXT
NBCC is a very useful method to reduce NMR. However state does not have adequate infrastructure to ensure quality utilization of the available services.

C. EXPECTED BENEFITS

The recommendations will relate to the Services, Design, Infrastructure, Equipments, Supplies and Human resource requirements for providing newborn care at various levels up to district hospitals. The TSP will hand hold the facilities for a period of one year towards effective implementation and utilisation of these facilities for sustainability

D. METHODOLOGY
A PPP based initiative will be affected where the Technical Service Provider will assure the State Govt. all Infrastructural and Process oriented services against a fixed fee. It will be the responsibility of the TSP to provide specialist manpower, train them and deploy effectively. The TSP consultants will provide twice a week visit to the facility.

E. SOURCE OF FUNDS
In order to strengthen neonatal services in the country, funds are provided to States for establishing and running Special Newborn Care Units (SNCU), Newborn Stabilization Units (NBSU) and Newborn Baby Care Corners (NBCC), train health care providers - Navjat Shishu Suraksha Karyakram (NSSK) & Janani Shishu Suraksha Karyakram (JSSK)

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 1 to 2 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project
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Improving Primary Healthcare in the state of Jammu & Kashmir

FIVE|STRENGTHENING EMERGENCY DEPARTMENTS FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS The accident and Emergency Care facilities of public hospitals are one of the main stay in the chain of medical care offered by the state govt. The need for purposeful emergency health care delivery through an Emergency Department is well recognised, and all hospitals/ PHCs must be able to provide basic life support through their Emergency Services to the patients in need within app. time

A. STATE SPECIFIC BACKGROUND

The state is today focusing on strengthening the infrastructure at Primary & Secondary level

B. NEED IN CONTEXT
With the strengthening of emergency referral ambulance services it has become imperative that the health care service providers starting from PHC onward to district hospitals have effective Emergency &triage systems in place to save critical lives.

C. EXPECTED BENEFITS
Strengthening of Emergency and safe referral services thereby saving lives Improved capacity to tackle disasters and emergency situations

D. METHODOLOGY
A PPP based initiative will be affected where the Technical Service Provider will assure the State Govt. all Infrastructural and Process oriented services against a fixed fee. It will be the responsibility of the TSP to facilitate procurement of all equipments and manpower, train them and deploy effectively. This service will link up with the existing 108 pre hospital emergency ambulance services.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 3 to 5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

SIX|SCHOOL HEALTH PROGRAM FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS A school health program is a program for school health services under NRHM which focuses on effective integration of health concerns through decentralized management at district with determinant of health like sanitation, hygiene, nutrition, safe drinking water, gender & social concern

A. STATE SPECIFIC BACKGROUND

The school health programme has been approved for implementation by the state

B. NEED IN CONTEXT
The school health programme is the only public sector programme specifically focused on school age children. Its main focus is to address the health needs of children, both physical and mental, and in addition, it provides for nutrition interventions, yoga facilities and counseling

C. EXPECTED BENEFITS
Screening, health care and referral Immunisation and Micronutrient (vitamin A & IFA) management
Capacity building

D. METHODOLOGY
Based on a cascading training strategy involving Health and Edu. Dept. ToTs will take place at state/District levels and teachers will be oriented. Apart from the teachers screening the children, area ANMs/MPWs will visit one school every wk for screening/ treatment of minor ailment/ referral. A Medical Officer will also visit one school per week for screening, treatment and referral

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 3 to 5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

SEVEN|STRENGTHENING OF VHND FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS
The Anganwadi Centre is identified as the hub for service provision in the RCH-II, NRHM, and also as a platform for inter-sectoral convergence. VHND is also to be seen as a platform for interfacing between the community and the health system.

A. STATE SPECIFIC BACKGROUND

One of the biggest challenges facing the state in the area of children and women development is high maternal mortality and neonatal mortality.

B. NEED IN CONTEXT
The Proposed Project will be a NRHM-funded technical assistance project designed to assist the Governments Maternal, Newborn and Child Health and Nutrition (MNCHN) programs in taking knowledge to practice at scale for improving MNCHN status.

C. EXPECTED BENEFITS

Improvement in the number & quality of VHNDs, including convergence, improved micro-planning & supp. for frontline workers and use of data for program review and improvement This project will help AWWs, ASHAs and PRI members to understand their respective roles in providing their services effectively to the community during the monthly VHND

D. METHODOLOGY
The training is meant to follow a cascade approach with Lead Trainers from the DJVOW Project training the Master Trainers, comprising of the District Activity Leaders (from representative community), technical team members of the associated Technical Assistance Agency if available, external trainers and selected District Programme Officers and Child Development Project Officers of ICDS.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between .5 to 1 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

EIGHT|TRAINING OF ASHAS FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS Launched in 2005, the NRHM promised an architectural correction of the health system, and placed for the first time, community Processes as one of its key components. Among many others the ASHA
and her support network at block, district and state levels was one of the flagship components

A. STATE SPECIFIC BACKGROUND

State has a sustained policy and programmatic commitment to provide support systems for the ASHA in the form of supervision and on the job mentoring through full time personnel, drug kits, performance based incentives and a range of non monetary benefits.

B. NEED IN CONTEXT
Collaboration between the ASHA, ANM and AWW has improved, and there is increasing responsiveness to the ASHA and her contributions from the health facilities. It is thus imperative that she be trained appropriately for her level of service in the community.

C. EXPECTED BENEFITS
Increase in skill sets to tackle maternal and neonatal morbidity Improved access to healthcare service providers by the community served by the ASHA

D. METHODOLOGY
The training is meant to follow a cascade approach with Lead Trainers from the DJVOW Project training the Master Trainers, comprising of the District Activity Leaders (from representative community), technical team members of the associated Technical Assistance Agency if available, external trainers and selected District Programme Officers.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 1 to 1.5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

NINE|OUTSOURCING OPERATION OF PHC FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS The NRHM has provisioned scope for providing outsourced clinical and preventive health services, implementation of the National Rural Health Mission (NRHM) and other National Health & Family Welfare Programmes, Health & Family Welfare related IEC activities through PPP

A. STATE SPECIFIC BACKGROUND

The state has many PHCs which are not functional or partially functional. They are in need of activation so that the watershed population can avail the primary health services.

B. NEED IN CONTEXT
PPP as an effective tool for improving healthcare can be used extensively to provide quality services through the existing infrastructure.

C. EXPECTED BENEFITS
Operationalisation of defunct PHCs

D. METHODOLOGY
The State government will short list the hospitals. The state will provide the entire infrastructure set up at a cost to NRHM. It will be operated by the agency against service charges.

E. SOURCE OF FUNDS
NRHM Flexi Pool B

F. APPROVING AUTHORITY
MD NRHM

G. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 2 to 5 Cr.

H. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project

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Improving Primary Healthcare in the state of Jammu & Kashmir

TEN|TELEMEDICINE LINKAGE & DIAGNOSTICS FOR J & K

CREATION OF NEW SERVICES AND INCREASING ACCESS Public-private partnership (PPP) has emerged as one of the important strategies for health sector reforms.

A. STATE SPECIFIC BACKGROUND

At present, there is no linkage between the health centres under the different projects in the state. If there is some linkages, the specialist doctors are mostly scattered and that too in the private sector and can be accessed by needy patients only after payment, thus providing an opportunity of a quantum jump in the rural health care if telemedicine facilities are implemented in the state.

B. NEED IN CONTEXT
Telemedicine facilitates the sharing of resources for providing services of specialist doctors in rural areas, which usually lack adequate medical personnel. As a result, people of rural areas usually have to travel long distances to far away specialty centers to get proper medical care.

C. EXPECTED BENEFITS
Higher level medical management of patients Distance Learning & Continuing Medical Education (CME) Training for isolated or rural health practitioners Video Conferencing for administrative purpose

D. METHODOLOGY
The State government will short list the hospitals. The PPP agency will provide the entire infrastructure set up at a cost to NRHM. It will be operated by the agency against service charges.

I. SOURCE OF FUNDS
NRHM Flexi Pool B

J. APPROVING AUTHORITY
MD NRHM

K. ESTIMATED PROJECT SIZE

For a state level initiative it can be between 2 to 5 Cr.

L. CURRENT STATUS OF PIP BASED APPROVAL

PIP supports the project
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